Cervical Spine Clearance in Trauma Patients with an Unreliable Physical Examination.

BACKGROUND: The objective of this study was to describe and compare the timing of cervical spine clearance in trauma patients with an unreliable physical examination. METHODS: We prospectively included adult trauma patients admitted with a cervical collar and an unreliable clinical examination (as defined by the NEXUS criteria) at two level 1 trauma centers: one in the USA (US) and one in Denmark (DK). We excluded patients with cervical spine injuries requiring a collar or surgery as treatment and patients with a collar placed after hospital arrival. The primary outcome was time from emergency department (ED) arrival to collar removal. Secondary outcomes included time to CT of the cervical spine (CTCS). At the US trauma center, an institutional protocol allowing cervical spine clearance exclusively by CTCS was in place. At the Danish trauma center, cervical spine clearance was based on a clinical evaluation by an orthopedic surgeon, usually after CTCS. RESULTS: A total of 113 patients were included (US: n = 56; DK: n = 57). The median age was 47 years, and 68% were males. The main reasons for an unreliable physical examination were a Glasgow Coma Scale score below 14 (35%), distracting injuries (26%), cervical spine tenderness (13%) and intoxication (13%). The injury severity score at the US trauma center was higher than at the DK trauma center (median: 17 vs. 11, p = 0.03). Both time to CTCS (median: 41 vs. 18 min, p < 0.0001) and time to collar removal (median: 1042 vs. 49 min, p < 0.0001) were significantly greater at the US trauma center. CONCLUSIONS: Time to collar removal was significantly greater in a trauma center utilizing a cervical spine clearance protocol based on CTCS. As patients may develop complications related to the collar, future studies should clarify how early removal can be implemented without increasing the risk of morbidity.

Ketamine for rapid sequence intubation in adult trauma patients: A retrospective observational study.

BACKGROUND: In the trauma population, ketamine is commonly used during rapid sequence induction. However, as ketamine has been associated with important side effects, this study sought to compare in-hospital mortality in trauma patients after induction with ketamine versus other induction agents. METHODS: We retrospectively identified adult trauma patients intubated in the pre-hospital phase or initially in the trauma bay at two urban level-1 trauma centers during a 2-year period using local trauma registries and medical records. In-hospital mortality was compared for patients intubated with ketamine versus other agents using logistic regression with adjustment for age, gender, Injury Severity Score (ISS), systolic blood pressure (SBP) < 90 mm Hg, and pre-hospital Glasgow Coma Scale (GCS) score. RESULTS: A total of 343 trauma patients were included with a median ISS of 25 [17-34]. The most frequently used induction agents were ketamine (36%) and propofol (36%) followed by etomidate (9%) and midazolam (5%). There was no difference in ISS or the presence of SBP <90 mm Hg according to the agent of choice, but the pre-hospital GCS score was higher for patients intubated with ketamine (median 8 vs 5, P = .001). The mortality for patients intubated with ketamine was 18% vs 27% for patients intubated with other agents (P = .14). This remained statistically insignificant in the multivariable logistic regression analysis (odds ratio 0.68 [0.33-1.41], P = .30). CONCLUSIONS: We found no statistically significant difference in mortality among patients intubated in the initial phase post-trauma with the use of ketamine compared with other agents (propofol, etomidate, or midazolam).

Spontaneous Retroperitoneal and Rectus Sheath Hemorrhage-Management, Risk Factors and Outcomes.

BACKGROUND: Spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH) is associated with high mortality in the literature, but studies on the subject are lacking. The objective of this study was to identify early predictors of the need for angiographic or surgical intervention (ASI) in patients with SRRSH and define risk factors for mortality. METHODS: We conducted a retrospective cohort study at a tertiary academic hospital. All patients with computed tomography-identified SRRSH between 2012 to 2017 were included. Exclusion criteria were age below 18 years, possible mechanical cause of SRRSH, aortic aneurysm rupture or dissection, and traumatic or iatrogenic sources of SRRSH. The primary outcome was the incidence of ASI and/or mortality. RESULTS: Of 100 patients included (median age 70 years, 52% males), 33% were transferred from another hospital, 82% patients were on therapeutic anticoagulation, and 90% had serious comorbidities. Overall mortality was 22%, but SRRSH-related mortality was only 6%. Sixteen patients underwent angiographic intervention (n = 10), surgical intervention (n = 5), or both (n = 1). Flank pain (OR 4.15, 95% CI 1.21-14.16, p = 0.023) and intravenous contrast extravasation (OR 3.89, 95% CI 1.23-12.27, p = 0.020) were independent predictors of ASI. Transfer from another hospital (OR 3.72, 95% CI 1.30-10.70, p = 0.015), age above 70 years (OR 4.24, 95% CI 1.25-14.32, p = 0.020), and systolic blood pressure below 110 mmHg at the time of diagnosis (OR 4.59, 95% CI 1.19-17.68, p = 0.027) were independent predictors of mortality. CONCLUSIONS: SRRSH is associated with high mortality but is typically not the direct cause. Most SRRSHs are self-limited and require no intervention. Pattern identification of ASI is hard.

Ketamine as a Rapid Sequence Induction Agent in the Trauma Population: A Systematic Review.

The choice of drug used to facilitate endotracheal intubation in trauma patients during rapid sequence induction (RSI) may have an impact on survival. Ketamine is commonly used in the hemodynamically unstable trauma patient although it has been associated with side effects. This review sought to investigate whether ketamine should be preferred over other induction agents for RSI in trauma patients. PubMed, Embase, and the Cochrane Library were systematically searched on September 19, 2016 for studies reporting RSI of adult trauma patients with ketamine compared with another induction agent (etomidate, propofol, thiopental, or midazolam). No language restrictions were applied. The primary outcome was 30-day mortality, and secondary outcomes included information on blood transfusions, length of hospital stay, and hospital mortality. Risk of bias was assessed using the Cochrane Risk of Bias assessment tool for randomized trials and the Risk of Bias in Non-Randomized Studies of Interventions for nonrandomized studies of intervention. A total of 4 studies were included. A cohort study from 1976 compared thiopental (n = 26) with ketamine (n = 14) for RSI in trauma patients. The primary outcome was number of blood transfusions, and no significant difference was found. Risk of bias was judged to be serious. A randomized controlled trial from 2009 compared etomidate (n = 57) with ketamine (n = 47) and found no significant difference in 28-day mortality (odds ratio [OR], 0.8 [0.4-2.0]). The trial was judged to have a low risk of bias. Two cohort studies from 2015 and 2017 also compared etomidate (n = 116 and n = 526) with ketamine (n = 145 and n = 442). No significant difference in hospital mortality between the groups was observed (OR, 1.11 [0.38-3.27] and OR, 1.41 [0.91-2.16], respectively). Both studies were judged to have a moderate risk of bias, thus excluding the possibility of a meaningful meta-analysis. The study from 2017 also reported number of units of blood transfused during the first 48 hours after trauma and length of hospital stay. No significant differences were observed (OR, 1.14 [0.87-1.49] and OR, 1.1 [0.95-1.27], respectively). Extremely few studies have compared induction agents for RSI in trauma patients. No significant differences have been found in mortality, length of hospital stay, or number of blood transfusions after induction with ketamine compared to other induction agents, but a clinically relevant benefit or harm cannot be excluded.

Supplemental oxygen and hyperoxemia in trauma patients: A prospective, observational study.

BACKGROUND: Supplemental oxygen is recommended during the initial treatment of trauma patients according to several guidelines, but the supporting evidence is sparse. We aimed to describe the use of supplemental oxygen and occurrence of hyperoxemia in the initial phase of trauma management at two level 1 trauma centers, TC1 and TC2. METHODS: In this prospective, observational study we included trauma patients ≥16 years of age. Data on pre- and in-hospital supplemental oxygen, arterial oxygen tension (PaO2 ), and outcomes (in-hospital mortality, hospital- and intensive care unit length of stay) were collected. RESULTS: We included 56 patients. There were 22 (39%) females with a mean age of 49 years (SD: 18) and a median Injury Severity Score of 9 (IQR: 4-14, n = 49). A total of 23 (45%) out of 51 spontaneously breathing patients received pre-hospital supplemental oxygen, but did not differ significantly from the patients that did not receive supplemental oxygen. In-hospital, 29 (59%) out of 49 spontaneously breathing patients received supplemental oxygen. The median PaO2 was 26.5 kPa [IQR: 22.2-34.1] in four intubated patients and 12.3 kPa [IQR: 9.7-25.7] in eight patients with spontaneous respiration on supplemental oxygen. At TC1 a significantly greater proportion of spontaneously breathing patients received both pre-hospital (TC1: 18 [64%]; TC2: 5 [21%], P = 0.002) and in-hospital (TC1: 24 [92%]; TC2: 7 [30%], P < 0.001) supplemental oxygen. CONCLUSION: Approximately 50% of trauma patients received supplemental oxygen during the initial treatment. Hyperoxemia was a common finding for patients treated with supplemental oxygen, and it was more pronounced in intubated patients.

Hemorrhage and saline resuscitation are associated with epigenetic and proteomic reprogramming in the rat lung.

BACKGROUND: Epigenetic changes have been described in trauma patients in the form of histone acetylation events, but whether DNA-methylation occurs remains unknown. We hypothesized that the combination of hemorrhage and saline resuscitation would alter DNA-methylation and associated proteomic profiles in the rat lung. METHODS: Ten rats were subjected to a pressure-controlled hemorrhage and resuscitation model consisting of hemorrhage to a mean arterial pressure (MAP) of 35mmHg for 90 minutes, followed by saline resuscitation to a MAP >70mmHg for 90 minutes (n=5) or sham (only anesthesia and cannulation). Lungs were harvested and subjected to reduced genome wide DNA-methylation analysis through bisulphite sequencing as well as proteomics analysis. Data was analyzed for differentially methylated regions and associated alterations in proteomic networks through a weighted correlation network analysis (WCNA). Pathway analysis was used to establish biological relevance of findings. RESULTS: Hemorrhage and saline resuscitation were associated with differential methylation of 353 sites across the genome compared to the sham group. Of these, 30 were localized to gene promoter regions, 31 to exon regions and 87 to intron regions. Network analysis identified an association between hemorrhage/resuscitation and DNA-methylation events located to genes involved in areas of endothelial and immune response signaling. The associated proteomic response was characterized by activations of mRNA processing as well as endothelial Nitric Oxide Synthase (eNOS) metabolism. CONCLUSION: We demonstrated an association between DNA-methylation and hemorrhage/saline resuscitation. These results suggest a potential role of DNA-methylation in the host response to injury.

Preoperative endoscopic retrograde cholangio-pancreatography (ERCP) is a risk factor for surgical site infections after laparoscopic cholecystectomy.

BACKGROUND: We sought to examine whether preoperative endoscopic retrograde cholangio-pancreatography (ERCP) increases the risk of surgical site infections (SSI) after laparoscopic cholecystectomy. METHODS: Patients admitted to an academic hospital from 2010 to 2016, who were older than 18 and had a laparoscopic or a laparoscopic converted to open cholecystectomy for complicated biliary tract disease were included. We compared those who had a preoperative ERCP to those who did not. Our primary endpoint was the rate of SSI. RESULTS: A total of 640 patients were included. Of them, 122 (19.1%) received preoperative ERCP and 518 (80.9%) did not. The former had different preoperative diagnoses compared to non-ERCP patients (choledocholithiasis [35.2%-7.0%], acute cholecystitis [31.2%-76.4%], gallstone pancreatitis [20.5%-16.2%], and cholangitis [13.1%-0.4%], p < 0.001). The rate of SSI was higher in the preoperative ERCP group (11.5%-4.0%, p = 0.005). In a multivariable analysis conversion to open (OR = 2.57, 95% CI = 1.06-6.21, p = 0.037) and preoperative ERCP (OR = 3.12, 95% CI = 1.34-7.22, p = 0.008) were the only independent predictors of SSI. CONCLUSION: Preoperative ERCP is associated with a threefold increase in the risk of SSI after laparoscopic cholecystectomy.

Cervical spinal cord injury after blunt assault: Just a pain in the neck?

BACKGROUND: We aimed to determine the incidence, risk factors, and outcomes of cervical spinal cord injury (CSCI) after blunt assault. METHODS: The ACS National Trauma Data Bank (NTDB) 2012 Research Data Set was used to identify victims of blunt assault using the ICD-9 E-codes 960.0, 968.2, 973. ICD-9 codes 805.00, 839.00, 806.00, 952.00 identified cervical vertebral fractures/dislocations and CSCI. Multivariable analyses were performed to identify independent predictors of CSCI. RESULTS: 14,835 (2%) out of 833,311 NTDB cases were blunt assault victims and thus included. 217 (1%) had cervical vertebral fracture/dislocation without CSCI; 57 (0.4%) had CSCI. Age ≥55 years was independently predictive of CSCI; assault by striking/thrown object, facial fracture, and intracranial injury predicted the absence of CSCI. 25 (0.02%) patients with CSCI underwent cervical spinal fusion. CONCLUSIONS: CSCI is rare after blunt assault. While the odds of CSCI increase with age, facial fracture or intracranial injury predicts the absence of CSCI. SUMMARY: The incidence, risk factors, and outcomes of cervical spinal cord injury (CSCI) after blunt assault was investigated. 14,835 blunt assault victims were identified; 217 had cervical vertebral fracture/dislocation without CSCI; 57 had CSCI. Age ≥55 years was found to independently predict CSCI, while assault by striking/thrown object, facial fracture, and intracranial injury predicted the absence of CSCI.

Operating at night does not increase the risk of intraoperative adverse events.

BACKGROUND: We sought to investigate the association between nighttime (NT) operating and the occurrence of intraoperative adverse events (iAEs). STUDY DESIGN: Our 2007-2012 institutional ACS-NSQIP and administrative databases were screened for iAEs using the ICD-9-CM-based Patient Safety Indicator "accidental puncture or laceration". Procedures were defined as AM (06.00-14.00 h), PM (14.00-22.00 h), or NT (22.00-06.00 h). Univariate and multivariable analyses were performed to investigate the association between PM and NT operating and the occurrence of iAEs. RESULTS: 9136 surgical procedures were included: 7445 AM, 1303 PM, 388 NT. iAEs occurred in 183 procedures. NT patients were younger and less comorbid, but sicker, and with less complex surgeries. There was no correlation between PM or NT operations and iAEs (multivariable analysis [reference: AM operations]: OR = 0.66 [95% CI = 0.40-1.12], P = 0.123; OR = 1.22 [95% CI = 0.51-2.93], P = 0.659, respectively). CONCLUSION: Operating at night does increase the risk of iAEs.

Bile Spillage as a Risk Factor for Surgical Site Infection after Laparoscopic Cholecystectomy: A Prospective Study of 1,001 Patients.

BACKGROUND: Bile spillage (BS) occurs frequently during laparoscopic cholecystectomy, yet its impact on postoperative outcomes remains unknown. We hypothesized that BS increases the risk of surgical site infections (SSI) after laparoscopic cholecystectomy. STUDY DESIGN: Patients older than 18, who were admitted to an academic hospital for a laparoscopic (or laparoscopic converted to open) cholecystectomy, from May 2010 to March 2017, were prospectively included. Open cholecystectomies were excluded. Patients were assessed clinically during hospitalization and 2 to 4 weeks after discharge. We compared those who had BS during the operation with those who did not. Our primary endpoint was the rate of SSI. Stepwise logistic regression was used to identify independent predictors of SSI. RESULTS: Of 1,001 patients, 49.9% underwent laparoscopic cholecystectomy for acute cholecystitis, 20.9% for symptomatic cholelithiasis or biliary colic, 12.8% for gallstone pancreatitis, and 16.4% for other indications. Bile was spilled intraoperatively in 591 patients (59.0%), with hydrops noted in 10.5% and empyema in 14.6% of them. In 202 (20.2%) patients, BS was accompanied by stone spillage. Patients with BS were older (median age of 52 vs 42, p < 0.001) and were more frequently male (44.8% vs 27.8%, p < 0.001). Conversion to open was more likely in operations with BS (13.0% vs 4.4%, p < 0.001). Bile spillage was associated with a higher SSI rate (7.1% vs 2.4%, p = 0.001) and longer hospital stay (median of 3 vs 2 days, p < 0.001). In the multivariable analysis, BS, conversion to open, and American Society of Anesthesiologists (ASA) score > 2 were independent predictors of SSI (odds ratios: 2.29, 2.46, and 2.1 respectively, p < 0.05). CONCLUSIONS: Bile spillage is associated with SSI, and surgeons should take extra caution to avoid it during laparoscopic cholecystectomy.